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    Using imaging to manage diabetic retinopathy

    Early detection leads to better treatment and visual outcomes

     

    OCT

    Spectral domain optical coherence tomography (SD-OCT) (Cirrus HD-OCT, Carl Zeiss Meditec; iVue, Optovue; Spectralis, Heidelberg Engineering; 3D OCT-1 Maestro, Topcon) has become essential in diagnosing and monitoring DME. In our experience, we have found that its use has led to a decrease in the amount of macular angiography imaging performed in recent years.


     

    Given that DME can be asymptomatic and present at any stage of the disease, OCT becomes a critical element in the assessment of DME. SD-OCT is also important in guiding continuous treatment. SD-OCT may prove to be valuable in the assessment of concomitant maculopathies, such as epiretinal membranes and vitreomacular traction. Additionally, it may help determine causes attributing to poor visual prognosis, such as the loss of photoreceptor integrity line.8

    Related: Using OCT with your diabetes patients

    Advancements in OCT have included the ability to evaluate the retinal vasculature without the use of dye. This novice tool is known as OCTA (AngioPlex OCT Angiography, Carl Zeiss Meditec; AngioVue, Optovue). The capillary plexus is an area of interest in the evaluation of patients with DR. OCTA’s use in evaluating patients with DR may aid in the proper identification of microaneurysms, which are often indiscernible using ophthalmoscopy alone, and yet they represent the earliest sign of the disease (mild NPDR). Additionally, subtle areas of IRMA or neovascularization are easily denoted using OCTA, which may not always be detected with ophthalmoscopy alone.

    Ischemia, which is a critical pathophysiology element of the underlying disease, may further be assessed using OCTA. It provides both structural and blood flow changes simultaneously at different layers of the retina. Alterations in both the retinal vasculature and structure may be invisible fundoscopically, and thus, both SD-OCT and OCTA can aid in the diagnosis of the disease and help to properly classified the stage of the disease.

    Looking ahead

    Creating a partnership between the optometrists and retinal practices will enhance the care of patients and serve as a continuing source of education and reference for the OD community. This constant communication will help diabetic patients who are suffering from this multifactorial disease that affects their bodies. DR must be addressed from the optometrist’s point of view, retinal specialist’s point of view, and the primary-care physician’s point of view.

    Related: How diabetes affects contact lens wear

     

    References

    1. Centers for Disease Control and Prevention. New CDC report: More than 100 million Americans have diabetes or prediabetes. Available at: https://www.cdc.gov/media/releases/2017/p0718-diabetes-report.html. Accessed August 11, 2017.

    2. Yau JW, Rogers SL, Kawasaki R, Lamoureux EL, Kowalski JW, Bek T, Chen SJ, Dekker JM, Fletcher A, Grauslund J, Haffner S, Hamman RF, Ikram MK, Kayama T, Klein BE, Klein R, Krishnaiah S, Mayurasakorn K, O'Hare JP, Orchard TJ, Porta M, Rema M, Roy MS, Sharma T, Shaw J, Taylor H, Tielsch JM, Varma R, Wang JJ, Wang N, West S, Xu L, Yasuda M, Zhang X, Mitchell P, Wong TY; Meta-Analysis for Eye Disease (META-EYE) Study Group. Meta-Analysis for Eye Disease (META-EYE) Study Group. Global prevalence and major risk factors of diabetic retinopathy. Diabetes Care. 2012 Mar;35(3):556-64.

    2. Romero-Aroca P. Managing diabetic macular edema: The leading cause of diabetes blindness. World J Diabetes. 2011 Jun 15;2(6):98-104.

    3. Early Treatment Diabetic Retinopathy Study Research Group. Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema. Early Treatment Diabetic Retinopathy Study Report Number 2. Early Treatment Diabetic Retinopathy Study Research Group. Ophthalmology. 1987 Jul;94(7):761-74.

    4. Johnson EL, Pfotenhauer K, Bradley S, Kalyani RR, Shubrook JH. Highlights From the American Diabetes Association's 2017 Standards of Medical Care in Diabetes for Osteopathic Physicians. J Am Osteopath Assoc. 2017 Jul 1;117(7):457-472.

    5. Wessel MM, Aaker GD, Parlitsis G, Cho M, D'Amico DJ, Kiss S. Ultra-wide-field angiography improves the detection and classification of diabetic retinopathy. Retina. 2012 Apr;32(4):785-91.

    6. Ghasemi Falavarjani K, Tsui I, Sadda SR. Ultra-wide-field imaging in diabetic retinopathy. Vision Res. 2017 Jul 20. pii: S0042-6989(17)30118-9. doi: 10.1016/j.visres.2017.02.009

    7. Diabetic Retinopathy Clinical Research Network. Panretinal photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: A randomized trial. JAMA 2015;314(20):2137-2146.

    8. Ruia S, Saxena S, Gemmy Cheung CM, Gilhotra JS, Lai TY. Spectral Domain Optical Coherence Tomography Features and Classification Systems for Diabetic Macular Edema: A Review. Asia Pac J Ophthalmol (Phila). 2016 Sep-Oct;5(5):360-7.

    Marco Gonzalez, MD
    Is retinal specialist at Retina Macula Specialists of Miami.
    Gary Shienbaum, MD
    Is retinal specialist at Retina Macula Specialists of Miami
    Diana Shectman, OD, FAAO
    Dr. Shechtman is a former professor at Nova Southeastern University College of Optometry. She is an advisor to Carl Zeiss Meditec, a ...

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